MEDICARE: ELGENDI DDS CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1437897501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELGENDI DDS CORPORATION

Provider Business Mailing Address
First Line	:	1161 HIDDEN VALLEY PKWY STE 106
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-3917
Country	:	US
Telephone Number	:	951-582-0200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1161 HIDDEN VALLEY PKWY STE 106
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-3917
Country	:	US
Telephone Number	:	951-582-0200
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. HAITHAM HAMZA ELGENDI
Credential	:	DDS
Telephone Number	:	951-582-0200

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	05/26/2022

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